December, 2010 - SUPPORT Summary of a systematic review | print this article |
Midwives are the primary providers of care for childbearing women around the world. In midwife-led care, midwives are the lead profes-sionals in the planning, organisation and delivery of care given to women from the initial booking to the postnatal period. Non-midwife models of care include obstetrician-provided care; family physician-provided care; and shared models of care, in which responsibility for the organisation and delivery of care is shared between different health professionals.
- Leads to fewer antenatal hospitalisations and instrumental vaginal deliveries
- Decreases the use of pain killers during labour
- Leads to more spontaneous vaginal births, and
- Probably has little or no effect on numbers of foetal and neonatal deaths, augmentation or induction of labour, caesarean sections, and postpartum haemorrhage
In most low- and middle-income countries, midwives are the primary providers of care for childbearing women. In midwife-led care, midwives are the lead professionals in the planning, organisation, and delivery of care given to women from initial antenatal bookings through to the postnatal period. Referrals to specialist obstetric care are provided as needed. The midwife-led model of care is woman-centred and based on the premise that pregnancy and birth are normal life events. Other models of care include obstetrician-provided care; family physician-provided care, including referral to specialist obstetric care as needed; and shared models of care, where responsibility for the organisation and delivery of care, from initial bookings through to the postnatal period, is shared between different health professionals.
This summary is based on a Cochrane review published in 2008 by Hatem and colleagues which aimed to synthesise available information on the effects of midwife-led care.
Review Objectives: To compare midwife-led care with other models of care for childbearing women and their infants. | ||
/ | What the review authors searched for | What the review authors found |
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Interventions | Randomised controlled trials comparing midwife-led care to other models of care |
11 randomised controlled trials |
Participants |
Pregnant women, classified as being at low or mixed risk of complications |
12,276 pregnant women recruited from both commu-nity and hospital settings |
Settings | Not pre-specified |
Australia (5 studies), Canada (1 study), United Kingdom (UK) (5 studies) |
Outcomes |
Antenatal, labour, delivery and immediate postpartum, neonatal, and maternal postpartum outcomes |
Antenatal, labour, delivery and immediate postpartum, neonatal, and maternal postpartum outcomes |
Date of most recent search: January 2008 | ||
Limitations: A good quality systematic review with only minor limitations |
Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. See in Cochrane Library
The review summarised 11 randomised controlled trials (RCTs) involving 12,276 women, conducted in high-income countries.
Five randomised trials reported data on antenatal hospitalisation, nine reported on foetal loss before 24 weeks, and 10 on overall foetal loss and neonatal death. A synthesis of these trials shows that:
Antenatal outcomes |
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Patient or population: Pregnant women at risks of complications which range from low to high Settings: Tertiary and community hospitals in Australia, Canada, and UK Intervention: Midwife-led care Comparison: Other models of care |
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Outcomes | Comparative risks* |
Relative effect (95% CI) |
Number of Participants (studies) |
Quality of the evidence (GRADE) |
|
Other models of care |
Midwife-led care |
||||
Antenatal hospitalisation |
263 per 1,000 |
237 per 1,000 |
RR 0.90 |
4,337 |
|
Foetal loss before 24 weeks |
45 per 1,000 |
36 per 1,000 |
RR 0.79 |
9,890 |
|
Overall foetal loss and neonatal death | 45 per 1,000 |
37 per 1,000 |
RR 0.83 |
11,806 |
|
CI: Confidence interval RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
Ten randomised controlled trials reported data on augmentation or induction of labour, five reported on use of intra-partum analgesia or anaesthesia, and 10 on induction of labour. These results, pooled together, show that:
Labour outcomes |
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Patient or population: Pregnant women at risks of complications which range from low to high Settings: Tertiary and community hospitals in Australia, Canada, and UK Intervention: Midwife-led care Comparison: Other models of care |
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Outcomes | Comparative risks* |
Relative effect (95% CI) |
Number of Participants (studies) |
Quality of the evidence (GRADE) |
|
Other models of care |
Midwife-led care |
||||
Augmentation of labour |
292 per 1,000 |
269 per 1,000 |
RR 0.92 |
11,709 |
|
No intrapartum analgesia |
167 per 1,000 |
194 per 1,000 |
RR 1.16 (1.05,1.29) |
7,039 |
|
Induction of labour | 194 per 1,000 |
182 per 1,000 |
RR 0.94 (0.83,1.06) |
11,711 |
|
CI: Confidence interval RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
Twelve RCTs reported data on caesarean sections, nine on spontaneous vaginal delivery, and seven on postpartum haemorrhage. Combining these results shows that compared to other models of care:
Delivery and immediate postpartum outcomes |
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Patient or population: Pregnant women at risks of complications which range from low to high Settings: Tertiary and community hospitals in Australia, Canada, and UK Intervention:Midwife-led care Comparison: Other models of care |
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Outcomes | Comparative risks* |
Relative effect (95% CI) |
Number of Participants (studies) |
Quality of the evidence (GRADE) |
|
Other models of care |
Midwife-led care |
||||
Caesarean birth |
124 per 1,000 |
119 per 1,000 |
RR 0.96 |
11,897 |
|
Spontaneous vaginal birth |
710 per 1,000 |
738 per 1,000 |
RR 1.04 (1.02, 1.06) |
10,926 |
|
Postpartum haemorrhage | 50 per 1,000 |
51 per 1,000 |
RR 1.02 (0.84, 1.23) |
8,454 |
|
Instrumental delivery | 125 per 1,000 |
108 per 1,000 |
RR 0.86 ( 0.78, 0.96 ) |
11,724 |
|
CI: Confidence interval RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
RCTs that reported neonatal and maternal postpartum outcomes show that:
Neonatal and maternal postpartum outcomes |
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Patient or population: Pregnant women at risks of complications which range from low to high Settings: UK, Australia Intervention: Midwife-led care Comparison: Other models of care |
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Outcomes | Comparative risks* |
Relative effect (95% CI) |
Number of Participants (studies) |
Quality of the evidence (GRADE) |
|
Other models of care |
Midwife-led care |
||||
Low birthweight |
63 per 1,000 |
62 per 1,000 |
RR 0.99 |
8,009 |
|
Preterm birth |
68 per 1,000 |
59 per 1,000 |
RR 0.87 (0.73,1.04) |
7,516 |
|
CI: Confidence interval RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
Findings | Interpretation* |
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APPLICABILITY | |
|
- The availability and training of midwives |
EQUITY | |
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ECONOMIC CONSIDERATIONS | |
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MONITORING & EVALUATION | |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low- and middle-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
Related literature
Muthu V, Fischbacher C. Free-standing midwife-led maternity units: a safe and effective alternative to hospital delivery for low-risk women?. Evidence-Based Healthcare and Public Health.2004;8:325-331.
Walsh D, Downe SM. Outcomes of free-standing, midwife-led birth centers: a structured review. Birth 2004;31:222-29.
Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth. Cochrane Database Syst Rev 2005 Jan 25;(1):CD000012.
Ciliska D, Hayward S, Thomas H, Mitchell A, Dobbins M, Underwood J, Rafael A, Martin E. A systematic overview of the effectiveness of home visiting as a delivery strategy for public health nursing interventions. Can J Public Health 1996; 87:193-98.
Kendrick D, Elkan R, Hewitt M, Dewey M, Blair M, Robinson J, Williams D, Brummell K. Does home visiting improve parenting and the quality of the home environment? A systematic review and meta analysis. Arch Dis Child 2000;82:443-51.
McNaughton DB. Nurse home visits to maternal-child clients: a review of intervention research. Public Health Nurs 2004;21:207-19.
This summary was prepared by
Charles Shey Wiysonge, School of Child and Adolescent Health, University of Cape Town, South Africa; Charles Okwundu, South African Cochrane Centre; Cape Town, South Africa
Conflict of interest
None. For details, see: Conflicts of Interest
Acknowledgements
This summary has been peer reviewed by: Jane Sandall, UK; Eugene J Kongnyuy, UK; Patricia McNiven, Canada; Eileen Hutton, Canada; Tracey Pérez Koehlmoos, Bangladesh.
This summary should be cited as
Wiysonge CS, Okwundu CI. Does midwife-led care improve the delivery of care to women during and after pregnancy? A SUPPORT Summary of a systematic review. December 2010.
This summary was prepared with additional support from:
University of Cape Town (UCT), South Africa. UCT aspires to become a premier academic meeting point between South Africa, the rest of Africa, and the world. Taking advantage of expanding global networks and our distinct vantage point in Africa, we are committed, through innovative research and scholarship, to grapple with the key issues of our natural and social worlds. www.uct.ac.za
The South African Cochrane Centre. The only centre of the international Cochrane Collaboration in Africa, aims to ensure that health care decision making in Africa is informed by high quality, timely and relevant research evidence. www.mrc.ac.za/cochrane/cochrane.htm